The Case for Primary Health Care

It’s 4:30AM. The sun isn’t up yet but Miss Dee is already making her way up the rocky lane to the main road of her community where she will catch the first ride going into town. In her purse she carries enough money for taxi fare both ways, two mint balls and a wrapped up piece of plastic with her tattered clinic appointment card and her last prescription. She will reach the clinic by 6AM so that she can collect one of the first numbers. When she arrives she is the third person there. They settle in to wait until 7:30 when the first security guard will open the gate.

Forty-one years ago in the city of Almaty, Kazakhstan, when Miss Dee was still a bright young girl, leaders from all over the world gathered to make a decision about keeping people healthy. The Declaration of Alma Ata, as it would come to be known, states firmly that primary health care is the key to achieving ‘Health for All’ – the universally accepted goal that promotes the health of all people.

Before we get into the nitty gritty, let’s get a few definitions out of the way. What is health, exactly? The World Health Organization defines health as “a state of complete mental, physical and social well-being, not merely the absence of disease or infirmity”. And they should know. This sounds like something everyone should have, right?

Health is a state of complete mental, physical and social well-being, not merely the absence of disease or infirmity

World Health Organization

Health for All‘ is the slogan for universal health coverage: no person or population gets left behind. Women, LGBTQ+, disabled individuals, persons living with HIV – everyone is included! Unfortunately, in some places, not everyone gets included all the time.

Now what is primary healthcare? This is a way of thinking about and organizing the different aspects of health care. Definitions of primary healthcare often make reference to essential health care and primary care (not the same thing). A primary health care system has a few key characteristics.

  • It’s based on principles that are scientifically sound, and socially acceptable
  • Primary healthcare is universal – it includes every single person
  • Primary healthcare aims to provide improved access to health services, financial risk protection and improved health outcomes

And finally primary care refers to those services that are delivered in the community (usually at a clinic or health centre) by doctors, nurses and allied health workers (also called primary care providers). These services are often someone’s first point of contact with the health care system.

So if primary health care is the key to achieving #HealthforAll, and if healthy people live better, stronger lives then investing in a strong primary health care system is the best and most cost-effective way to ensure a healthy, productive population.

Investing in a strong primary health care system is the best and most cost-effective way to ensure a healthy, productive population.

Remember Miss Dee from earlier? She’s not real, but her story is. This clinic-before-daybreak sojourn is the reality for a majority of citizens who access services at health centres (clinics) in Jamaica. People leave home early hoping that they will get through the clinic quickly. But in reality reaching clinic by 6AM doesn’t guarantee that Miss Dee will be finished before 10AM or even before noon. Depending on the type of clinic, number of patients, availability of staff or occurrence of emergencies, Miss Dee may end up waiting until 3PM or later before she’s seen by a medical doctor (her primary reason for going to clinic in the first place). And remember she only brought enough money for transportation – not for lunch – and she left home too early to have a proper breakfast.

Public health care in Jamaica is a running joke. Meaning, the kind of joke people run from. Letters to editors, prime time news stories, and overheard conversations complain about common themes like long wait times, rude staff, lack of resources, lack of space and limited accessibility. The feeling of the man on the street (who only complains to overburdened health care staff and never to his chair-cushioned and air-conditioned MP) is that average people, poor people, who need and use these services are grossly neglected. Politicians and the well-to-do get private, highly resourced health care but the woman on the street gets what the duck got.

So what actually is the situation? The Layman’s Doctor recently posted a guide for people accessing care at their local health centres, in which she specifically addressed the notoriously long wait times and cautioned patients to prepare for it. For people who don’t work in or don’t access care in these clinics, it can seem like another world.

There are large crowds on days when a doctor is present at the clinic, and often the seating provided is inadequate. As we approach the summer months, there is no air conditioning, and clinics in the country don’t always have fans installed. The patient to staff ratio is usually high, which further prolongs the wait time, and to top it off most health centres do not have a pharmacy attached. This means that after seeing the physician patients have to get their medication at another (sometimes inaccessible) location, that may or may not have all the drugs they need.

If you’re frustrated just reading this, you aren’t alone. Experts the world over have agreed that accessible and universal primary care is critical to improving health outcomes. That means that people with diabetes won’t get their legs chopped off, and people diagnosed as obese can be prevented from getting diabetes in the first place.

Primary care providers save lives

WHO, 2018

In their technical series on primary health care the WHO reviewed systematic reviews and meta-analyses from a broad sweep of countries. The results were unanimous. When it comes to people dying (all-cause and specific-cause mortality), there is strong evidence that supplying primary care providers (ie clinic staff) leads to less people dying overall. Primary care providers save lives, y’all. And strong evidence that continuity of care (meaning the same doctor, same facility or strong linkages between doctors and facilities) also leads to less people dying.

For people who care more about the bottom line, the same review also examined health system efficiency (ie best bang for the buck). They found strong evidence that a supply of primary care providers reduces the number of avoidable hospitalizations, and evidence that case management programmes (think social workers) could reduce the number of total hospitalizations as well.

And for the social justice warriors (because health care is a human right), there is evidence that primary care, as compared with other types of health care, can improve access to health services, especially for disadvantaged adults.

Full disclosure – most of these studies took place in English-speaking high income countries but the evidence can be translated universally. Read the full 28-page review here: The Economic Case for Primary Care.

So if you were Minister of Health and you had to decide how to spend the meager Health budget, how would you allocate the funds? In Jamaica there are no user fees for nationals at public facilities (this does not mean health care is free!), so all the money comes from you (and a few donor agencies). You have to keep hospitals open, keep clinics running, pay your staff, provide medication, refurbish and maintain equipment, buy resources and develop media campaigns that remind people to “love yuh body, treat yuh body right“.

What’s your number one priority?

If you guessed hospitals – then you’d be right. . . Right on the side of our current Health Ministry, which is the wrong side.

Hospitals are undeniably important to the delivery of health care. Secondary and tertiary centres (smaller and larger hospitals) are vital and necessary, but they are vital and necessary in the way that having a spare tire is necessary. They’re super important if you get a flat tire, but it’s way simpler and easier to invest your time in avoiding a flat tire in the first place.

Now I know what you’re thinking – “But I can’t control when I get a flat tire!!”. And I hear you, shit happens. You drop into a pothole on the North South highway and pow! Yuh haffi draw fi di spare. But suppose you were using your spare tire every single day? If you had to choose between keeping your tires in good condition and avoiding potholes or buying a really expensive spare tire (complete with repairing the damaged tire, and the loss of work time that it’s going to take you to get the tires sorted out) which would you choose?

I really want to know, so leave a comment with your pick. And if you’re one of those brilliant minds out there thinking that this wouldn’t have happened if the roads were properly maintained in the first place then congratulations, you’ve just hit on another pillar of primary care – multi-sectoral policy and action. Because there are a lot of other things in the world that impact a person’s health, not just access to health services.

What I’m trying to say in my long rambling way is that investing the bulk of health budgets into hospitals isn’t going to yield any long-term improvement in the health of the population. Hospitals are necessary to deal with emergencies but, as we’ve shown, having a strong primary care system means there won’t be as many emergencies. A robust primary care system can handle minor emergencies and prevent major ones, reducing the burden on the hospitals and other referral centres.

So back to Miss Dee. By pouring more time and energy and investment into making primary care stronger, better and more effective Miss Dee won’t feel compelled to leave her house in the pitch-dark pre-dawn, risking ankle and foot injury on the uneven road. She could get to clinic at 8:30 or even 9 for her appointment, do her checks and see the doctor by 10, then get her medication (for free) at the same facility and return home in time for lunch. If we invested the right way, with the needs of the patient at the heart of our activities then even if Miss Dee was a 16 year old lesbian seeking advice on safe sex, or an 80 year old blind woman in a wheelchair she would have the same access, protection and positive outcome.

Health isn’t just for the good of the individual, it’s for the good of the country. Healthy people are more productive, and more healthy working people means more GDP. It’s time for all our leaders to make good on their promise – ‘Health for All’ is a human right.

on the Legitimacy of ‘Free’ Health Care

Disclaimer: Opinions reflected here are my own, and not representative of any other person or entity. This post isn’t even about a specific country. It’s entirely hypothetical. Any resemblance to actual places or policies is completely coincidental and should be ignored.

No person in need should be refused health care because they are unable to afford it.

If someone is sick they should get be able to access the treatment and investigations they need without going bankrupt. This is what the World Health Organization considers ‘Health for All‘.

uhc_healthforall

 

But health systems need to be sustainable. Governments shouldn’t promise health care gratis and then serve up a substandard product. Free service with unacceptable wait times, drug shortages and costly basic interventions is impractical and unfair to the population receiving it. It’s free health care in name only, a political tactic, and frankly demeaning to the patients who must navigate these inaccessible territories.

Being able to get medical help without having to pay through the nose is great! I see a doctor at my local clinic for free, get a prescription which I fill at the nearest government pharmacy for free. If I need blood work, an x-ray or ultrasound, those are all free too. If I need to be hospitalised, I don’t need to worry about a bill, and I can rest assured that the hospital has all the resources required to treat me according to international standards.

But what if there are not enough doctors in the clinic, or not enough space in the hospital? What if there isn’t enough medicine in the pharmacy, what if the machines for blood testing or x-ray or ultrasound aren’t working? What if the hospital is overwhelmed by demand and its resources are inadequate for a population this size?  What happens then?

I don’t have the answers but I’m sure the solution is more complicated than just throwing more money at the problem. Sustainability and capacity building are nuanced and necessary concepts that demand to be addressed. Failing to take them into consideration results in a quagmire of dissatisfaction and deteriorating quality.

If high quality, patient-centered health for all is the goal, then the steps to get there must reflect this realignment of values. Any health system that decides to serve users at no charge must remember that it exists to serve, and not to inconvenience or ignore its customers.

Big Pharma in Little Jamrock

a Third World Perspective on the Ethical Dilemma of Drug Company Gifts

Who doesn’t love presents? Santa Clause, your mom, your boy/girlfriend – doesn’t matter who it’s coming from, as along as the tag has your name on it (and you don’t have to pay). Can you imagine if you could get presents, not only from people who care about you, but from people you associate with in the professional sphere?

What, presents from work colleagues? Not quite. Gifts and privileges from medical representatives trying to push their products. What’s the harm, you might ask. I’ll take their stuff, but my prescriptions don’t have to change. Besides, so what if I prescribe Brand X instead of Brand Y. The patient still gets the same drug.

But there’s plenty of harm.

Multi-million dollar pharmaceutical companies, affectionately called Big Pharma, spend tidy sums of money each year keeping physicians loyal to their brands. This comes across as fancy dinners, paid vacations, or even just catered meetings. The medical representative proffers the olive branch of food (usually) in return for the chance to remind physicians why we need to prescribe their pills.

This, of course, can have disastrous repercussions for patient care, particularly when the ethical practices of physicians are called into question. For this reason the relationship between doctors and drug companies is heavily regulated in the United States and other countries. But in Jamaica physicians are left up to their own devices when handling drug company influences.

For the most part the attitude of Jamaican doctors appears to be politely non-partisan. We’re appreciative of the benefits meted out by medical representatives, but brand loyalty isn’t a widely supported concept*.

In medical school our lecturers went to great lengths to teach generic names instead of brands for common drugs. It’s a habit that sticks until you start working with doctors who almost exclusively use trade/brand names and then all our lecturers’ hard work is undone. And strictly prescribing generics becomes impractical when you start to consider affordability, brand vs. generic efficacy (and there is a difference) and of course patient preference. Most of our choices as doctors will be based on one or more of these factors, not just which company gave us better stuff.

Another aspect of third world presents that differs from our first world counterparts is the quality and scale of the benefits. I hear stories (from the U.S.) of travel expenses being covered and expensive electronics being gifted to conference attendees. Big Pharma has even literally paid doctors cash to recommend their products.

Now I am a still a small fry in this medical business, but I just don’t see Lil Pharma here in the Caribbean shelling out that kind of money. We get catered lunch meetings and one or two free conferences for medical education purposes, but the average ‘kickback‘ here is most often a pen or some hand sanitizer. Really, it’s like they’re not even trying (by comparison).

But this doesn’t necessarily mean we aren’t being swayed. Especially when you add in other local factors like how Jamaica is so small that chances are you’re actually friends with one or two medical representatives (and so feel compelled to prescribe their drugs). Or how Jamaica has so much corruption that even if physicians practiced unethical brand loyalty people would probably still turn a blind eye. On the other hand, Jamaica is so poor that most patients aren’t able to afford fancy brands anyway so it’s not much use pushing those medications on our market.

This is where public and private practice diverge widely. Patients in the public system are treated based on availability of medication because for the most part they cannot afford to pay full price for their medications. Pharmaceutical companies sometimes bid for spots on the National Health Fund subsidy so that their drug can reach a wider base. Yay, right? Not necessarily. These are the cheaper drugs, often generic formulations and usually older than what the rest of the world is using. Standard of care takes a back seat to any kind of care we can manage at this point.

By contrast in private practice, patients are generally seen as wealthier and more actively involved in their health. These patients usually don’t mind paying more for a brand name medicine if they feel it works better than the generic, and this is where the industry can get a toe in the door. This is where the ethical dilemma of industry gifts begins to take root. And if we are going to start any kind of regulatory or even supervisory process this is where we must investigate first.

But for now people are comfortable. Patients get their medications, physicians get their food, and Big Pharma gets their profits. It’s a win-win-win, until someone (likely the patient) loses.


*Not statistical. Based on my own (limited) observations.

St. James: warm, welcoming, dangerous, defensive

This parish is a bundle of contradictions. While we smile and wave at tourists on the Hip Strip, lotto scammers fleece hundreds of thousands of dollars from unsuspecting (and greedy) foreigners. Upscale communities like Mango Walk and Ironshore are book-ended by their less refined counterparts Paradise and Flankers. In and around Montego Bay we are a thriving urban cesspool but you don’t have to drive too far out of town to find coconut groves, yam grounds and the occasional babbling brook.

When I went to Flamstead for a health fair Obie told me to make sure I got some coconuts (apparently Flamstead has good coconuts?). I ended up coming home with more than just coconuts, thanks to the generosity of rural folk and the fertile farmland that the community is nestled in.

In fact the good experiences I had at the health fair were entirely due to a brand of kindness that too many Jamaicans are growing up without these days. The church members who hosted us were more than accommodating, and the clients we interacted with were so polite! A far cry from the average short-tempered clinic patient. Jamaicans generally have a problem with patience (meaning we have very little) but aside from some minor hiccups the day was very productive.

As a thank-you gift (and because we asked, shamelessly) the church pastor sent us off with yam, sugar cane and other goodies. Even though I didn’t get home until after 6 I would gladly trade any sweltering unfriendly clinic shift with another day in the field like that one.

By strong and glaring contrast my home visits in the community of Flanker were filled with sharp zinc fences, sketchy looking dirt tracks and suspicious neighbours. Going to someone’s home is totally different from going to their community; home visits are a lot more intimate, and the experience was an eye-opener.

The contradictory nature of St. James came out full force again. Though it is a stone’s throw away from the planned upscale development of Ironshore, Flanker has a lot of captured land* and it is well known for having a violent streak. But while the stereotypical cruffs* congregated at every corner shop, behind the high gated walls you can find middle aged career types, retired couples and aging invalids. Yes, there were the common twenty-something girls with artificially lightened skin and lengthened hair, but in the same place a dirt road might actually lead to a house with floor-to-ceiling windows overlooking the beautiful bay.

I left Flamstead with gratitude. I left Flanker with grounding.

In my dispassionate survey of these alternate living situations, I recognized that there is no one way to be Jamaican, to be uptown or even to be ‘ghetto’.  Neighbourhood lines and bank accounts don’t always gel, and poverty cannot be measured solely on the basis of ones weekly income. I recognized that the struggle was so much realer that I could have imagined, because it was many struggles rolled in to one. How old you are impacts how much money you make impacts where you can afford to live impacts your access to health care. The intersections of the biological, psychological and social spheres of health were made suddenly and painfully alive.

But despite my personal revelations St. James will continue to woo visitors with visions of sandy beaches and gorgeous sunsets, while hiding their less savoury vistas behind highway rails and zinc fences. When will we improve the pathetic social infrastructure that is dragging our economy down? When will we realize that a nation’s people are its best investment?

 

**
Cruff – unemployed male, usually in his twenties, who spends his days smoking weed, drinking rum and Boom and catcalling any girls unfortunate enough to pass by

Capture(d) land – land that isn’t legally owned (yet) by the person living on it

Self-Censored

I struggle a lot with what I want to write about in this space, with what I’m allowed to write about. I’m very conscious of people in real life who pay attention to this blog (few though you may be, thank you for existing) and that makes me want to be careful with what I put in here.

It doesn’t help that I work in a field that is big on confidentiality (of the patient kind and the cover your ass kind) and most of my work stress (which is most of my life stress) comes from government issues and bureaucratic issues that people in charge would probably frown at me for flaunting.

Now I strongly feel that these issues need to be flaunted, and the issues that affect the health care system ought to be a matter of public record. But a part of me (probably the part of me that is my mother) hesitates, wondering if my voice needs to be the one shouting in the wilderness. Because there are usually only two kinds of voices that shout into the wild, and neither of them are very well-loved.

Not that I’m afraid of consequences – even though I probably should be – but I feel like distance is needed in order for clarity to emerge. Objectivity is perhaps better in hindsight. The kind of hindsight that lets me write deliberately rather than rashly. If I’m going to be frowned at I want my actions to be worth it.

Distance is growing, and objectivity with it. I hope I will soon be able to write about the issues that affect me as a person without worrying about whether I’m compromising the institutions I work for. Whether these institutions deserve to be compromised (or are already compromised) is another matter entirely.

Pax.

Type Sea Hospital 

Noel Holmes Hospital sits almost on the edge of a cliff. Strong sea winds whip around tree branches, hairstyles, the odd piece of gravel. As you approach the edge the gust steals your voice, dulls your hearing. 

The hospital is a little thing, boutique in size if not style. There is nothing cute or trendy about it. Type C is the first hospital grade, a step up from the Type 5 health centre. There is a general ward, a maternity ward and a space for overnight observation. Staff is limited and patients are relatively few; cases are simple. The days are short, the workers friendly. Time passes in the island way. 

Historically, Fort Charlotte (where the building rests) defended Hanover from seafaring enemies. This bastion now turns inward, defends against a sinister more pervasive threat. Primary caregivers work hard to prevent the spread of illness, and control chronic disease. 
Our success or failure depends on the whim of patients and the dictates of a disinterested administration. Noel Holmes is a boat adrift, but does the tide drag it toward or away from the safer shore? 

Hospitals, Presidential Campaigns and Other Things Badly in Need of Repair

Once again CRH is splashed across the media – and right on schedule, it was about this time last year that the neonatal scandal surfaced. This time the papers are focused on the gradual loss of hospital services – clinics, the lab and pharmacy are operating at less than 50% capacity with no proposed timeline for the return of function.

The primary issue is one of air quality, with administrators pointing fingers at the Radiology department for “Xray fumes” that have leaked all over the first three floors of the hospital due to “faulty ventilation”. The problem is being rectified slowly, and “experts from PAHO” have been called in, six months after the fact. Remember in April when the lab was down? Turns out it was an early manifestation of the same problem.

However the root of the problem is simple – the entire system of public health has been left to struggle along for too many years without the necessary financial attention.

The problems at Cornwall are the result of an aging infrastructure that has not been given the repairs and maintenance it needs to be functional. When you have a CT machine that works 40-50% of the time because it is old and routine maintenance is not up to scratch, that’s just a symptom of the disease.

This isn’t new though. Last year the Gleaner ran an article about how under-resourced the health facilities are in the Western Region. Minister of Health Christopher Tufton was quoted in the newspaper as saying:

“Frankly, it is an indication again that the infrastructure of the public health system in Jamaica is plodding because of limited capital investment in the sector over time, expanding population, much greater demand and usage, and all of that combined has made the system ripe for reform,”

Health reform is desperately needed, and its going to take a lot more than just three experts from PAHO.

Meanwhile in Foreign…

I’m going to admit something that’s a little unusual for a middle class Jamaican – I’ve never actually been to the United States of America. Not Disneyland, or New York or California. Not even a visit to Canada. North American soil has never had the pleasure of meeting my feet.

And with the way the US election is going, I may never ever get there. On the background of worsening racial friction and ingrained unrelenting sexism, the presidential campaign is breaking the glass ceiling and rock bottom at the same time (quote stolen from Twitter).

What I find crazy is how many people do not actively hate Donald Trump. People I work with, people I consider intellectuals, (these are also people with no ballot to cast of course) are not as convinced as I am to vote for anyone except Trump. Usually I can consider alternate points of view with aplomb – I have no issues working with or talking to people who’s ideas are different from my own. But this political debate has absolutely polarized me. I don’t care about his policies or his economics – he is too horrible a creature to become the next POTUS.

Of course Hilary isn’t a saint – no politician is. But she has experience and the common sense not to piss off and alienate large groups of people (in public). And as a nation which is often cast in America’s shadow, that’s really about as much as we can ask for.

Unless (hopefully) Obama decides to stay permanently in office.